Provider Demographics
NPI:1053353839
Name:VANMERSBERGEN, MIRIAM (SLP)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:VANMERSBERGEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:
Other - Last Name:VAN MERSBERGEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SLP
Mailing Address - Street 1:850 POPLAR AVE BLDG 2
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-4607
Mailing Address - Country:US
Mailing Address - Phone:901-287-5565
Mailing Address - Fax:
Practice Address - Street 1:4055 N PARK LOOP
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38152-8011
Practice Address - Country:US
Practice Address - Phone:901-678-2009
Practice Address - Fax:901-678-5497
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6315235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist